An exploration of the social determinants of the health and well-being among older African immigrants living in San Diego. A socio-ecological approach

Institutional review board statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the University of California, San Diego’s Institutional Review Board (IRB: #201634; approval date 15/10/2021). Prior to the study, informed consent was obtained from potential participants. Verbal as opposed to written consent was obtained from participants. The IRB agreed upon verbal consent as many refugees cannot read or write. To obtain consent, the first author (PM) read and explained the contents of the information sheet, upon which participants were given time to reflect on the information provided and an opportunity to ask questions. This entire process was audio recorded.

Research setting

This study was conducted in San Diego County, the second most populous county in California, and the fifth largest in the U.S. There are currently 3.1 million people living in San Diego, 21.5% of who are immigrants²⁵. African immigrants have contributed greatly to the growth of immigrants in San Diego, growing by about 53.8% in the past five years. It is estimated that by 2030 the number of African immigrants will exceed those coming from Europe to settle in San Diego²⁶. The county’s ethnic diversity is expected to grow in the coming years and the number of older and disabled populations are increasing disproportionately compared to the rest of the population (https://www.sandiegocounty.gov/hhsa/statistics_demographics.html).

In California, older adults aged 65 or older and people with severe disability receive social security income (SSI) monthly. SSI is a federally funded program which provides cash to meet basic needs for food, clothing, and shelter. Beneficiaries can also qualify for Medicaid to meet their hospital and doctor’s bills, purchase medications and pay for other medical services supplies. Medi-Cal is California’s Medicaid healthcare program and covers most medically necessary preventive health care and annual check-ups. Beneficiaries can also avail of mental healthcare, substance use disorder services, prescription drugs and medical supplies, transportation, in-home personal assistance, dental and vision (eye) care, foot care, hearing aids and long-term care. Medi-Cal can help with transportation to health care appointments and transportation to collect prescriptions and medical supplies²⁷. Older adults and disabled non-citizens not eligible for SSI as a result of their immigrant status can apply for the Cash Assistance Programme for Immigrants (CAPI) whose payment standards are equivalent to the amount of SSI benefits²⁸. To qualify for Medi-Cal, one must meet certain income and residency requirements. Refugees and legal immigrants need to get naturalized (which requires passing an English language and civics test) within the first seven years of being in the U.S. to continue enjoying these benefits.

Participants and procedures

This study employed a qualitative approach and was conducted between April and July 2022. The study was part of a wider study that examined dementia and barriers to care among refugees in San Diego. Study participants had to be older adults aged >60 years of age and living in San Diego. Participants were recruited via the Somali Family Services (SFS) a “community-based social service organization that provides culturally and linguistically appropriate programs and services to refugee and immigrant communities in San Diego”.

Prior to the study, two community health workers (CHWs) from SFS approached potential participants (face to face) to introduce the researcher and the study, and to explain the purpose and nature of the proposed study. The researcher also attended virtual townhall meetings convened by SFS to introduce the study. Using convenience sampling we recruited and interviewed 11 participants (nine females and two males). We used semi-structured interviews to explore four broad topics with participants: pre-migration and postmigration experiences, perception of one’s current health status, health, and social care services available to older adults and perception of these services. The interview guide²⁹ was created by the authors and informed by the literature⁶. Interviews were conducted by PM in participants’ homes. The interviews were conducted in participants’ local languages; Swahili, Kinyarwanda, Kirudi and Krahn. Two CHWs and one caregiver acted as interpreters. The interviews lasted between 30 minutes to an hour. All interviews were audio-recorded, and the audio data were transcribed verbatim. Participants received a USD 35 gift card as compensation for their time.

Data analysis

We adopted Braun and Clark’s³⁰ thematic analysis approach to identify, analyse and report patterns (themes) emerging from the transcripts and the analysis was conducted manually, without the use of any software. According to Braun and Clark³⁰ a theme captures something important about the data in relation to the research question, and represents some level of patterned response or meaning within the data set. The themes were identified deductively³¹ and hence data were coded based on a pre-determined coding frame (the five layers of the SEM framework). We adhered to Braun and Clark’s³⁰ guide to thematic analysis which entails six phases. The first phase involved familiarising with the data; as PM was involved in data collection and transcribing the data verbatim, this provided a good starting point to familiarise with the data³². Phase two entailed the generation of initial codes which was done manually. The process entailed making notes on the transcripts being analysed and the initial codes identified were then matched up with data segments in the transcripts that illustrated that code. In phase three, identified codes where organised into potential candidate themes and the next phase (four) involved reviewing and refining the identified themes and generating a thematic “map’ of the analysis. This phase was closely linked to phase five which entails “identifying the essence of what each theme is about (as well as the themes overall), and determining what aspect of the data each theme captures”³⁰. The thematic process was iterative rather than linear and generated themes and sub-themes were discussed with the second author prior to the write-up of the thematic analysis (phase six). The five levels of the SEM framework (individual, interpersonal, organizational, community and public policy) were the main themes from which 15 subthemes were identified.

Participant characteristics

Of the 11 participants recruited for the study, eight were refugees and three were migrants. Most (n=6) were originally from the Democratic Republic of Congo, two from Rwanda and the rest from Burundi, Ghana, and Liberia. Participants were aged between 62 and 90 years and participants’ number of children ranged between three and eight. In total, two of the participants were married, eight were widows and one widower. A total of four participants had attained secondary level education, three had a primary education, one had attended adult education and three were uneducated. The refugees’ time in the U.S. ranged between six months to 22 years. The three migrants had arrived on a visitor visa with the most recent arrival being January 2022. All but one male participant were living with family members and one participant was living in a senior home. The average size of participants’ households was 2.5 persons with three households having six or more people. The majority (n=9) were receiving support services from SFS.

Participants were asked to assess of their own health and described it as follows; ‘great’ (n=1), ‘much improved’(n=3), ‘not bad’ n=1, ‘not good’ n=4 and ‘declined/deteriorated’ (n=2). One participant who described her health as great talked of being happy and content with life in the U.S. (P5, Female). Participants who talked of poor/declining health were either recent arrivals (P10, Female) with no access to medical or social care or those who were not receiving SSI/CAPI benefits due to immigration status (P6, Female). Demographic characteristics of study participants are shown in Table 1.

Themes identified based on the socio-ecological model

Individual factors

Pre-migration and migration experiences and impact on health

This sub-theme captures the experiences with migration and how the stress of migration impacted health. One participant who had lived in several refugee camps prior to moving to the U.S. described how this experience could potentially impact one’s health particularly that of older adults.

Other participants related the political tensions in their home countries that had forced them to flee to the U.S. and how these experiences left them with psychological scars.

One male participant lauded the efforts of refugee organizations and state agencies in the U.S. that were involved in resettling and integrating refugees when he arrived in the U.S. 13 years ago. He maintained that this support made it possible for him to receive emotional and material support during a difficult and stressful period of his life.

Aging-related health decline

Some participants linked their poor health to aging, suggesting that there is not much that could be done to reverse the process. According to one male participant,

Another participant, who viewed her health as much improved since moving to the U.S. was less optimistic that she would continue to be in good health. She maintained that her health would eventually deteriorate with age.

Side effects of medications

All participants were on medications, with most using multiple medications daily. Some attributed medications to their declining health, while others believed that the side effects of medications led to further health problems.

This sentiment was shared by two other participants who believed that medications were linked to their declining health.

Sedentary behaviours and physical activity

Sedentary behaviours (SB) regarded as ‘too much sitting’³³ were noted among study participants and most, were physically inactive. Several participants spent long hours sitting watching television or simply lying down and few engaged in physical activities such as walking or doing household chores. Participants’ age, poor physical health, disability, and boredom were linked to SB and physical inactivity. One participant with a physical disability (P1, Female) spent all her time sleeping and sitting and needed fulltime care and another noted ‘I do not go out much, most of the time I am here indoors’ (P9, Female). In another instance, the participant’s housing situation coupled with deteriorating physical health contributed to her SB and inactivity.

Yet, some participants talked of being physically active. A participant stated that ‘I walk a lot, every five minutes, I don’t sit down’ (P11, Female). Another participant (P5, Female) reported that ‘In the morning before the sun comes out, I go out for a walk to the park to exercise. I come back here, shower, dress and then sit here and just relax’. These two participants reported relatively fewer health challenges compared to other study participants and had rated their health as ‘great’ (P5, Female) and ‘much improved. (P11, Female).

Diet and food choices

Some participants attributed their declining health to the diet in the U.S. and talked of inadequate food choices for those with chronic conditions.

One participant seemed frustrated by her deteriorating health even though she had strived to maintain a healthy diet.

Interpersonal factors

Social networks

Close relationships or the lack-thereof between participants and their social network (family members, friends, neighbours) appeared to influence health and well-being. We asked participants about their social network and how often they met up with friends. Most did not have many friends and those who had them did not see them regularly. According to one female participant, ‘Apart from going to church, I never really go out to meet other people of my age’ (P9, Female). One newly arrived participant (in the U.S for six months) stated that ‘Here, who are you going to meet up with? I don’t meet with anyone here’ (P10, Female). Another female participant who had lived in the U.S. for five years noted that ‘I only have one friend, but we barely see each other because she lives on the other side of town’ (P11, Female). However, one participant noted that ‘I have many friends who come here and make us laugh so it’s like I am not alone’ (P3).

Emotional and practical support from close family members as well as neighbours was regarded as key to help promote health and well-being.

However, one male participant, a widower, was disconnected from his close family. Despite having grown up children living in the U.S. he had little contact with them as some did not stay in touch.

Social participation

There was an emphasis on the importance of social programs and activities for seniors to encourage social interactions and promote well-being.

Organizational factors

This theme relates to healthcare and support services and how these were structured to support the health and well-being of older adults. We asked participants to identify what services they had accessed and what factors promoted or curtailed the use of these services.

Access to healthcare and support services

Specific services mentioned included prescription drugs (n=10), medical supplies and devices such as wheelchairs (n=6), in home personal assistance (n=4), transportation to doctors’ appointments (n=3) chronic disease management (n=5), physical therapy (n=1), dental (n=1) and vision (eye) care (n=1). One newly arrived participant without health insurance had not accessed any health care services. Most participants (n=9) had Medi-Cal and saw their doctors on a regular basis.

Some were seen by doctors in the comfort of their own homes, and in some cases, consultations involved a mix of face-to face and virtual consultations.

Doctors regularly advised and encouraged participants to make healthy lifestyle choices to promote their well-being and help manage chronic diseases. Some participants talked of receiving information from their doctors about healthy food choices and on how to stay physically active.

However, few participants mentioned availing of routine health checks such as eye and dental services. Only one participant talked of availing of dental care and yet this service was free for those with Medi-Cal (n=9). Similarly, despite having access to free eye care services, one participant in need of prescription glasses had not updated them since moving to the U.S.

Transportation and language barriers

Although participants with Medi-Cal could avail of free transportation to healthcare services, some participants still cited transportation as a key barrier to accessing services.

Some participants also talked of the need to have someone accompany them during doctors’ appointments, either to drive them there or provide translation as majority are not conversant in English:

Disruption to services due to COVID-19

There was consensus among participants that the disruption to services due to the pandemic had affected their ability to access some services. Some of the services had been reduced or discontinued.

Perception of healthcare and support services

Most participants expressed satisfaction with the care they received from their physicians and services availed through Medi-Cal:

One participant felt overwhelmed by the equipment given to her to help manage her health and felt that the prescribed medication was doing little to improve her health.

Community factors

Social, emotional, and practical support

We adopted the McLeroy et al.²² description of community to refer to the mediating structures which can influence individuals’ beliefs, values and norms including health seeking behaviours and attitudes. These structures are a vital source of social resources and can include religious, voluntary or neighbourhood organisations. In San Diego, SFS is one such organisation. It is non-profit community-based organization which aims to promote the health and well-being of the underserved refugee and immigrant communities. CHWs support the delivery of services and hence serve as an important link between older adults, the SFS and the wider health and social service systems. Participants highlighted the influential role that SFS plays in providing older adults with social, emotional, and practical support.

Connecting older adults to services

The role of SFS in helping to link older adults, who had lost their benefits due to immigration status, to other programs was highlighted by participants. Some participants talked of how SFS assisted them to find financial programs and make applications for low-income housing.

To reduce barriers to accessing care SFS also provided transportation services to older adults to attend appointments.

Public policy factors

Financial barriers

Study participants were not employed. Most, (n=9), were receiving government support through the SSI/CAPI programs to cater for their basic needs (medical, food, clothing, and shelter). Those not in receipt of this support (n=2) relied on family members. Some were content with the financial support, as noted by two participants.

But for other participants, this financial support was far from adequate. Some participants talked of struggling to pay their rent and could not find affordable housing. They attributed their financial difficulties to the high cost of living in San Diego.

According to one participant who was not receiving SSI benefits:

Participants also talked of struggling to afford healthy foods.

Several participants expressed the need for the government to increase financial support for older adults.

Immigration policies and legal status

Legal immigrants in the U.S, including refugees are eligible for SSI but need to apply to be naturalised within the first seven years to continue receiving SSI benefits. The main barrier for older adults is the English language and civics test required to get naturalised. Most of the participants we interviewed had no education and most could not read or write in English. Inability to become a citizen puts SSI beneficiaries at risk of losing their benefits making it impossible to seek healthcare services and meet their basic needs as described by several participants:

Some participants talked of the impact of loss of benefits on older people and the need for the government to intervene.

Table 2 indicates themes and sub-themes based on the socio-ecological model.

Study implications

As immigration continues to be a global phenomenon, the number of aging immigrants will increase, demanding that health, social and legal policies are responsive to this growing and diverse population. There is a knowledge gap in the U.S. context on the social determinants of health among older African immigrants which limits the potential to highlight their needs and precludes the ability to inform the development of migrant-sensitive health, social and legal policies. We contend that, for such policies to be responsive and culturally suited to this population, they need to be informed by evidence-based research; preferably research that is designed and conducted collaboratively with immigrant communities and supporting organizations.

Community organizations, such as the SFS, were considered a lifeline by most participants as they are a vital source of emotional, social, and practical support. These organizations require sufficient and reliable funding to ensure uninterrupted provision of support and services. There is need for further work to understand the impact of local organizations in reducing barriers and enhancing access to services among underserved immigrant populations⁴³.

Highlighted in our study is the impact of immigration policies (such as those linked to health insurance eligibility) on access to health and social care services. While most of our study participants were covered under the Medi-Cal program, some had lost health insurance and other benefits for failure to pass citizenship tests. Although some exemptions apply based of age, residency years and medical grounds, study participants not naturalized did not qualify for these exemptions. Immigration policy changes are urgently needed to ensure that older immigrants from low-income backgrounds who face linguistic barriers have a pathway to citizenship or can continue to receive social security benefits despite their legal status.

Study limitations

First, the small sample size of our study is a key limitation of our study and the participants we interviewed do not reflect the diversity of older immigrants from the African continent. This makes it difficult to draw inferences beyond the population studied. Future research should strive to include a bigger and diverse sample.

Second, our study was limited to the perspectives of older adults in terms of exploring the health influencing factors. Given the interlinkages of the factors identified in this study, further work should examine these factors from the community, organizational and public policy perspectives. This can help better inform the design of interventions that would potentially yield favourable health outcomes for older adults.

Third, older adult males were underrepresented in our study sample. Health promotion programs have reported a number of barriers that preclude male participation in their programs such as culture, health beliefs, gender roles and age⁵¹ and future work should aim to include more males.

Finally, most of the participants (n=9) we interviewed were supported by SFS. The experiences and health needs of our study participants may differ from those not linked with local organisations such as SFS. Future research could explore the needs of older African immigrants with limited social resources.